Mindfulness-Based Versus Health Promotion Group Therapy After Traumatic Brain Injury.

The current pre- and posttest intervention study is designed for individuals with chronic symptoms and stress associated with mild-to-moderate traumatic brain injury (TBI). The researchers' intent was to evaluate whether an 8-week mindfulness-based group therapy compared to health promotion active control group therapy reduces chronic stress, TBI symptoms, and depressive symptoms. Significant mean reductions in chronic stress and TBI depressive and general symptoms for individuals in the mindfulness group compared to the active control group were present, according to paired t test analyses. Further, while controlling for baseline scores, the mindfulness-based intervention group change score was greater compared to the control group using regression analyses. Results suggest that mindfulness-based group intervention for individuals with chronic difficulties after TBI is feasible and effective. Further study of this cost-effective and self-management approach to stress and symptom management is warranted and has the potential to be a broad-based intervention for early therapy after injury. [Journal of Psychosocial Nursing and Mental Health Services, 57(1), 26-33.].

Transition to Critical Care Practice Within an Academic-Service Partnership: A Case Report of the First 3 Years of Clinical Immersion in Trauma-Burn and Neuroscience Critical Care.

In response to regulators of nursing education and the Institute of Medicine, an academic-service partnership was formed between a research-intensive school of nursing and a tertiary health care facility. In that partnership, clinical experiences occurred mostly within 1 organization. This case report showcases the development, implementation, and revisions within our capstone immersion course, designed to ease the new graduates' transition into practice, including transitions to critical care nursing. Herein, we highlight our successes and challenges of implementing the clinical component within 2 critical care units focused on trauma and neurosurgical care of complex patients. Its purpose is to describe the planning and orientation phase, illustrate the mentoring processes used to achieve the educational outcomes, and describe the benefits and challenges of such an immersion experience. Our redesigned clinical immersion course in high-acuity nursing is facilitated by our partnership and resulted in improved RN-NCLEX rates, facilitation of best practices, and ease of transition into novice graduate nurse roles.

Development and testing of two lifestyle interventions for persons with chronic mild-to-moderate traumatic brain injury: Acceptability and feasibility.

This clinical methods discursive highlights the development, piloting, and evaluation of two group interventions designed for persons who experienced chronic traumatic brain injury (TBI). Intervention science for this population is limited and lacking in rigor. Our innovative approach to customize existing interventions and develop parallel delivery methods guided by Allostatic Load theory is presented and preliminary results described. Overall, parallel group interventions delivered by trained leaders with mental health expertise were acceptable and feasible for persons who reported being depressed, stressed, and symptomatic. They reported being satisfied with the overall programs and mostly satisfied with the individual classes. Attendance was over the anticipated 70% expected rate and changes in daily living habits were reported by participants. These two group interventions show promise in helping persons to self manage their chronic stress and symptomatology.

Scholarly productivity for nursing clinical track faculty.

Recent years have yielded substantial advancement by clinical track faculty in cohort expansion and collective contributions to the discipline of nursing. As a result, standards for progression and promotion for clinical faculty need to be more fully developed, articulated, and disseminated. Our school formed a task force to examine benchmarks for the progression and promotion of clinical faculty across schools of nursing, with the goal of guiding faculty, reviewers, and decision makers about what constitutes excellence in scholarly productivity. Results from analyses of curriculum vitae of clinical professors or associate professors at six universities with high research activity revealed a variety of productivity among clinical track members, which included notable diversity in the types of scholarly products. Findings from this project help quantify types of scholarship for clinical faculty at the time of promotion. This work provides a springboard for greater understanding of the contributions of clinical track faculty to nursing practice.

Determinants of subjective memory complaints in community-dwelling adults with mild-to-moderate traumatic brain injury.

PRIMARY OBJECTIVE: This study sought to determine to what extent chronic stress, depression and neurobehavioural consequences explained post-TBI subjective memory complaints (SMC). RESEARCH DESIGN: An observational, cross-sectional design was used. METHODS AND PROCEDURES: One hundred and fifty-nine persons who were 1-36 months post-injury provided data using interviews, chart reviews and surveys. Predictor variables included the Center for Epidemiological Studies-Depression Scale (CES-D), Perceived Stress Scale (PSS-14) and sub-scales of the NFI. MAIN OUTCOMES AND RESULTS: SMC, according to the Neurobehavioural Functioning Inventory (NFI), was the main outcome variable. SMC could best be explained by increased age, months-since-injury, chronic situational stress and the frequency of somatic and communication difficulties, not depression (R(2)= 0.780, F = 97.39, [8, 152], p < 0.001). These findings suggest that, for persons in the chronic phase of recovery from their TBI, specific determinants other than general adjustment issues may apply. These include: increased chronic stress, age, somatic symptoms and communication difficulties. CONCLUSION: Self-reported chronic situational stress is positively associated with self-reported memory complaints, as well as somatic and communication difficulties. The causal ordering of these relationships would be best understood with prospective designs using biological correlates of chronic stress to advance understanding of post-TBI depression in older adults.

Chronic stress, somatic and depressive symptoms following mild to moderate traumatic brain injury.

Despite advances in research on symptoms, stress, and depression after traumatic brain injury, there has been limited focus on the collective relationships between neurocognitive performance, chronic stress, and somatic and depressive symptoms. Guided by our adaptation of the allostatic load theory, we examined relationships between chronic stress, somatic and depressive symptoms, and cognitive performance using the Immediate Postconcussion Assessment and Cognitive Testing cognitive battery. Only somatic symptoms and chronic stress explained variation in depressive symptoms (R(2) = .71, P < .0001), not neurocognitive performance, preinjury, or injury-specific variables. Our findings suggest that increased chronic stress and somatic symptoms can contribute significantly to depressive symptoms after mild to moderate traumatic brain injury.

Chronic stress and fatigue-related quality of life after mild to moderate traumatic brain injury.

OBJECTIVE: To determine relationships among chronic stress, fatigue-related quality of life (QOL-F), and related covariates after mild to moderate traumatic brain injury (TBI). DESIGN: Observational and cross-sectional. PARTICIPANTS: A total of 84 community-dwelling individuals with mild to moderate TBI recruited from multiple out patient rehabilitation clinics assessed on average 15 months after injury. METHOD: Self-report surveys and chart abstraction. MEASURES: Neurofunctional Behavioral Inventory, Perceived Stress Scale-14, Impact of Events Scale, McGill Pain Short-form Scale, and modified version of the Fatigue Impact Scale. RESULTS: QOL-F was associated with somatic symptoms, perceived situational stress, but not with event-related stress (posttraumatic stress disorder symptoms) related to index TBI, preinjury demographic, or postinjury characteristics. Somatic symptoms and chronic situational stress accounted for 42% of the variance in QOL-F. CONCLUSIONS: QOL-F in community-dwelling individuals with mild to moderate TBI is associated with chronic situational stress and somatic symptoms. Symptom management strategies may need to include general stress management to reduce fatigue burden and improve quality of life.

Functional status, chronic stress, and cortisol response after mild-to-moderate traumatic brain injury.

It is well known that individuals experience difficulties with depressive symptoms and functional status after traumatic brain injury. However, it is unclear what the relationship is between these 2 phenomena and whether there is a biological explanation for. In this secondary analysis, we examined whether depressive symptoms explained postinjury functional status and whether chronic stress and salivary cortisol influenced this relationship. Participants included 75 persons within 24 months of their injury dates who were evaluated or treated in specialty clinics. All participants and a family member or significant other completed survey data, and 50 of the participants provided cortisol data. Results indicated that chronic stress, measured using Cohen's Perceived Stress Scale, completely mediated the relationship between depressive symptoms, measured using the Center for Epidemiological Studies Depression Scale, and psychological functioning, measured using the Patient Competency Rating Scale. Furthermore, those who provided cortisol data displayed hypocortisolemia in their 12-hr profile. Results from this analysis suggest that interventions focused on addressing the chronic stress experience may be important in limiting depressive symptoms and improving psychological functioning. Longitudinal study of this phenomenon is required to understand the progression of chronic stress after traumatic brain injury.

Psychological and biological correlates of fatigue after mild-to-moderate traumatic brain injury.

Relationships between chronic perceived stress, cortisol response (area under the curve) and posttraumatic brain injury fatigue were examined with persons from outpatient settings. Seventy-five injured persons with traumatic brain injury and their relatives/significant others participated in this cross-sectional study. Using interviews and self-reported data from the Neurofunctional Behavioral Inventory, the Perceived Stress Scale, the Profile of Mood States-Fatigue subscale, the McGill Pain Scale, as well as self-collection of salivary cortisol over a 12-hour period (N = 50), we found that perceived chronic stress explained 40% of the variance in fatigue until depressive symptoms and pain were in the model. Hypocortisolemia was evident. Somatic symptom frequency and perceived chronic stress represented 50% of the variability in post-TBI fatigue. Fatigue and stress management interventions, as suggested in the Centers for Disease Control Acute Concussion guidelines, may be beneficial in reducing this common symptom.

Sex differences in depressive symptoms and their correlates after mild-to-moderate traumatic brain injury.

The purpose of this secondary data analysis, guided by allostatic load theory, was to compare depressive symptoms and their correlates in men and women following mild or moderate traumatic brain injury (n = 159). Using general linear modeling procedures in the Statistical Analysis Software, women reported significantly higher Center for Epidemiological Studies-Depression scores compared with men. According to the Neurobehavioral Functioning inventory subscales, women also reported higher somatic and motor symptoms and difficulties with memory and cognition. Further, women within the first 6 months of their injury reported higher levels of depressive and depressive-somatic symptoms, perceived chronic stress, pain, memory difficulties, and somatic symptoms. These findings were no longer present at the 6- to 12-month or >12-month cutoffs. Women's depressive symptoms during the early recovery period are explained by higher symptom loads and perceived stress, yet mechanisms responsible for these differences remain to be elucidated. Future research is needed to describe hormonal, perceptual, or brain structure differences that may account for these findings. Findings from such research will most likely to contribute to our understanding of postconcussion syndrome.

Mild traumatic brain injury: an update for advanced practice nurses.

Nearly 75% of persons with brain injury experience a mild injury. These people do not often enter the healthcare system by traditional means, nor do they always present with visible signs and symptoms of injury. In fact, people who experienced brain trauma are likely to seek help in primary care settings and from advanced practice nurses (APNs). Because the symptom experience can be complicated by impaired perception or mood, delays in seeking help, and faulty explanations for their symptoms, APNs need to rule out competing diagnoses, offer brief psychoeducational treatment, and refer the person to an appropriate specialist for therapy when needed.

An Academic-Service Partnership: A System-Wide Approach and Case Report.

BACKGROUND: An academic-service partnership was formed to increase educational capacity, improve evidence-based nursing at the point of care, and engage staff nurses, clinical faculty, and students in patient and family care. METHOD: This case report reflects an overview of the first year of full implementation, and survey results from nurse leaders and faculty at the 3-year time point. RESULTS: Following its third year of an academic-service partnership, the shared mission, vision, and values have resulted in stronger NCLEX-RN results, improved quality initiatives, and trends for improvements in patient outcomes. Alignment with faculty and mentors surrounding student expectations has improved, as well as shared evidence-based practices. CONCLUSION: Sustaining an academic-service partnership requires dedicated leaders, faculty, and mentors. This partnership continues to thrive and move toward excellence in patient- and family-centered outcomes and undergraduate clinical education. [J Nurs Educ. 2017;56(6):373-377.].

Prevention Strategies in Post-TBI Depression in Older Adults: A Case Study.

PURPOSE: The purpose of this study was to describe a theoretically focused intervention aimed toward chronic stress and depressive symptom management that is coordinated by a case manager and delivered within a home environment by the caregiver. PRIMARY PRACTICE SETTING: Home care, community setting. METHODS: A case study of an older adult with traumatic brain injury (TBI) secondary to a fall who had significant allostatic load at the time of his injury. "Allostatic load" is a theoretical construct that suggests the brain is experiencing chronic strain on its systems that flexibly respond to stressors. Sustained allostatic load can contribute to chronic conditions and poor outcomes. FINDINGS: Through actions with the family as caregivers, the case manager was able to coordinate a structured home setting and gradual resumption of social activities for this older adult. Focus was on establishing structure, meaningful social interactions, and positive home experiences that maximized the older adult's interests and capacity and mitigated chronic stress. Gradually, the older adult returned to his preinjury capacity and lives independently within the family home. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The case management process has the potential to mitigate stressors and improve depression management through family-focused care. Although there is limited guidance on prevention of depression, this approach resulted in attainment of safe home care, no hospital readmissions, and return to previous lifestyle for the older adult. This could be useful in the prevention of post-TBI depression.

A professionalism and safety code of conduct designed for undergraduate nursing students.

Nationally, professionalism and safety are key concepts in nursing practice. Although they are traditionally viewed as individual concepts, we believe they are closely linked to and depend on one another. Herein, professionalism and safety are developed as a paired concept with specific indicators. The purpose of this paper is to describe the process used to develop and implement a professionalism and safety Code of Conduct for undergraduate nursing students and to share the end product of this process. Based on input from students, faculty, and health system partners in our academic-service partnership, the current definition and Code include six student behavioral domains: communication, self-awareness, self-care, professional image, responsible learning, and personal accountability. Our Code of Conduct is now a program policy and published in both the Student Handbook and clinical syllabi. Compliance is expected. Still under development are progressive clinical grading rubrics for inclusion in every clinical course.

Symptom experience and emotional distress after traumatic brain injury.

Traumatic brain injury (TBI) is unexpected and affects nearly 1.5 million Americans annually. Many with seemingly minor injuries incur long-lasting symptoms without clear explanation. This study examined the symptom experience and emotional response of persons with mild-to-moderate TBI and was guided by the University of California San Francisco (UCSF) symptom management model. Using a cross-sectional design with persons recruited from outpatient rehabilitation settings, we found a positive and significant relationship between postinjury symptom frequency and tension/anxiety, anger/hostility and perceived chronic stress, implying a need to understand these relationships over time in order to implement symptom management strategies.

Chronic stress, salivary cortisol response, interpersonal relatedness, and depression among community-dwelling survivors of traumatic brain injury.

Depression is a common mood disorder after traumatic brain injury (TBI). Largely, study of this phenomenon is theoretical and without biological measures. This explanatory study, guided by McEwen's allostasis model of stress, examined relationships among chronic stress, salivary cortisol profiles, post-injury depression, and interpersonal relatedness. Seventy-five participants, who were or had participated in outpatient brain injury rehabilitation therapies and experienced mild-to-moderate levels of brain injury, were recruited for this cross-sectional study. Salivary cortisol levels showed the usual patterns of circadian rhythmicity, and those with milder injuries had higher 8 am cortisol levels. Salivary cortisol values were not related to measures of chronic stress, interpersonal relatedness, or depression with two exceptions. The 8 am and noon mean values were significantly greater for those who reported more pre-injury childhood adversity, while the 8 pm cortisol mean level was associated with the frequency of pre-injury stressful life events. For this outpatient sample, salivary cortisol levels do not appear to be elevated after TBI or to lack circadian rhythmicity as previously reported. There may be some value in using this measure as a correlate with persons treated in specialized TBI clinics who report pre-injury chronic stress, but future studies are needed with TBI persons who were not treated in specialized clinics or were not taking medications known to influence the hypothalamic-pituitary-adrenal axis.

Mentoring the next generation of neuroscience nurses: a pilot study of mentor engagement within an academic-service partnership.

Resulting from a system-wide launch of an academic-service partnership that united a research-intensive School of Nursing and a tertiary healthcare system, neuroscience nurses used a team-based approach in mentoring undergraduate nursing students in neuroscience nursing. They linked their team approach to the Institute of Medicine's Future of Nursing report and American Association of Neuroscience Nurses' (2012) strategic plan to prepare neuroscience nurses for the future. Using case reports containing both the mentors' and students' perspective, we showcase sophomore nursing students' development in neuroscience nursing with focus on their developing skills in competency, leadership, and collaboration. Results from this implementation phase include improved reliability in performing undergraduate neurological assessments; developing competency in collaborating with the health team using a culturally sensitive approach; beginning leadership in managing a patient with seizures; and collaborating with families in patient-family-focused care. Evaluation of the effectiveness of this mentored approach to clinical undergraduate nursing education will focus on confidence building for students and mentors.

Chronic morbidities after traumatic brain injury: an update for the advanced practice nurse.

Emerging data suggest that traumatic brain injury (TBI) is a disease process with considerable long-range morbidities requiring lifelong monitoring and treatment. Multiple chronic morbidities develop across the life span after TBI, including mental health disorders, headaches, seizures, and neuroendocrine imbalances as well as chronic diseases. Still, there has been limited focus on effective guides and strategies for helping persons with TBI meet their chronic health needs as they live with the consequences of TBI. The advanced practice nurse is well positioned to participate collaboratively in practices that promote health screening and chronic disease management after TBI to ameliorate distress and enhance quality of life as persons with TBI live with lifelong consequences.

Are there gender differences in cognitive function, chronic stress, and neurobehavioral symptoms after mild-to-moderate traumatic brain injury?

Research is inconclusive on whether gender differences exist in cognitive function in persons who sustain a mild-to-moderate traumatic brain injury (TBI). Furthermore, it is also unclear whether there is a relationship between chronic stress and cognitive function in these persons. The purpose of this integrative review is to determine whether gender differences exist in cognitive function, neurobehavioral symptoms, and chronic stress levels after a mild-to-moderate TBI. Participants (n = 72) were recruited from eight outpatient rehabilitation centers. Participants completed the demographic questions, the Immediate Postconcussion Assessment Cognitive Testing neurocognitive test battery, the Perceived Stress Scale-14, and the Neurobehavioral Functioning Inventory (NFI). Gender differences were present on verbal memory composite scores (p = .033), with women performing worse than men. There were no other between-gender differences on cognitive tasks, neurobehavioral symptoms, or chronic stress. Higher chronic stress levels result in a decrease in verbal memory (p = .015) and motor processing speed (p = .006) and slower reaction time (p = .007) for women. As male NFI cognition scores increased, motor processing speed scores decreased (p = .012) and reaction time got slower (p = .019), whereas women exhibited decreased verbal memory (p = .017) and slower reaction time (p = .034). As NFI motor symptoms increased, men exhibited decreased verbal memory (p = .005), visual memory (p = .002), and motor processing speed (p = .002) and slower reaction time (p = .002). Overall, this study only found gender differences on verbal memory composite scores, whereas the remaining cognitive tasks, neurobehavioral symptoms, and chronic stress did not indicate gender differences. Correlations between chronic stress, neurobehavioral symptoms, and cognitive function differed in both men and women with TBI. Persons in the chronic phase of recovery from a TBI may benefit from training in compensatory strategies for verbal memory deficits and stress management.